04100145 CITY OF CUPPRITN zY. 'yg'-
BUILDING DIVISION PI✓RN._ CONTRACTOR INFORM ON
year, w' a,. k,. iwhr
BUILDING ADDRESS: MARTIN & JENNIFER PARRY PERMIT N®4100145
697 GALWAY DR
OWNER'S NAME: PERMIT ISSUE DATE
MARTIN & JENNIFER PARRY 10 21 2004
HON&
SANITARY NO, CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
0 0 0 0
Lop LICENSED CONTRACTOR'S DECLARATION
XU I hereby affirm That 1 am licensed under pmvisionx of Chapter v(commencing Job Description
stew with Scniun 70(110 of DfVmI a.li dw Business and Preressiof hapter9 e...timing
^_`m`w in full forte arta effect OPEN CEILING/FLUO. LITS
3 n K. License Class Lic.p
,�n Date Contriam
y~tl ARCHITECTS DECLARATION
Y K a 1 understand my plans shall M used u public records
ca
;oy�6u �e�ll�►L
Licensed Professional
H
g OWNER BUILDER DECLARATION
d< hereby m0rm that 1 am exempt from the Contractors License Law for the
ED
O O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K m which requires a permit m Construct,alter,improve,demolish,or repair any structu e $270
w—H priori its issmnee.insumulmuheappllcaat for such pemit n Bie aligned lonarem
that he is licensed policeman the pmvvmmufthc Contractors Lams Law(Chapter 9 Sq. _ r a Valuation -
yF0 (commencing with Section7")rat Division 3 of the Business and Professions Code)or r J
W. that he is exempt Iherefram and the basis for the alleged exemption.Any violation of _ _
section 7071.5 by any applicant for a permit subjeeu me applicant to a civil penalty of Occupancy Type
not more(ban five hundred dollars(5500).
1,u owner of the pmpeny,or my employees with wages az their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7BM,Business
and Professions Code:The Connector's License Law dos not apply to an owner of Required Inspections
property who builds or improves auction,and whodma such work himself or though his
own employees,provided that uch improvements are not intended or offered for sale.If.
however,the building or improvement is mid within one year of completion,the owner-
Wil`,,will have the burden of proving Nat he did not build of improve far purpose of
salcJ.
❑1,as owner of she property,am exclusively contracting with licensed contractors 10
constmet the project(Sec.7044,Business and Professions Code:)7Tc Contractor's Li.
crime Law docs net apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects with a enmractm(a)licensed pursuant m the Contractor's
Li rax Law.
O�nc n/Y'!✓'1 Da�01Qsr� n
�UI
WORK 'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Ccnificam of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 7700 of Ne labor Code.for Ne performance of the
work for which this mmit is issued.
❑1 have and will maintain Worker's Compensation insurance,az required by Section _
37M of the labor Code,for she performance or the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier: Pal icy No.:
CERTIFICATE OF EKEM MON FROM WORK BBS'
COMPENSATION INSURANCE
(Thu section need not W completed if the Permit is for one hundred dollars(SIM)
rr less)
I ceni Iv that in the performance of the work for which this Permit is ismed,l shall not
employ any pe:as yy anncSL,r�a9� to bpm subjeumthe Workeri Compensation
Lawsof CaliforuL n/1 lCsl�f lV�\
Applicant I/A'lIrT ^s
NOTICE TO AP A :If,after making this Centralia of Emarnim,you should
became Subject to the Worker's Compensation provisions of the Labor Codc.you must
�7 rofthwith comply with such previsions or Ibis Permit shall W deemed revoked.
'Z O CONSTRUCTION LENDING AGENCY
'[— IM1cahy affirm Nat there is a construction lending agency fnnhe Performance of
C the work fur which his permit is issued(Sec.7097.Civ.C.) j
IL1 Q Lrndcr's Name
6. u deli's Address
J Z
V Q 1 certify that 1 have rend this application and stem that dm oborc im inning is
building comply fig, F ilding 1 agree to with all city and county ordinances and sum lawswsrelating to ,r•
0
F^ 4 ngconiwdtionand herebytioprdprdescrepresentatives of this city to enter upon the
abovementioned for inspection urposs
(We)agree to saw.indcmart'and keep
/
hay inantheynaof Cupertino against
N incormarjudgmc ts.the costs and c(this parm it. may in anyway accme against said City
Oz into myucnccufthc gmming of this permit
^ APP NT NDERSTANOS AND WILL COMPLY ONHAL NON-POINT Issued by: Dale � r
SO'J��ATIONS. (o1f�f �ULI
WD
C�� Re-roofs
Signature til'A,,liaturatiCininextia, Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ser(Muni buildings,Chart store or andhandle Health and
az darned by plc Cupcnino Municipal Code,Chapter 9.12.and the Health and Safety
Cada,Section 2553210)7 All roofs shall be inspected prior to any roofing material being installed.
El Ycs �No
Will the applicmtor ce buildingocuupamumcyuipmemordcvicuwhicA If a roof is installed without first obtaining an inspection,I agree to remove
emit haiafdous air contaminants az defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Ycs No
I how mad the mmado s materials requirements under Chapter 6.95 of the Cali for.
ilia HcalthKSafcg Cndc,Sections 255115.255)7 and 25574.1 understanJ lhanif me building
dr<s dad have a tenant mat It is my responsibility w ran,IW tw'mpanr of me
myui Mil
ihmustMmctpriorinissuanceofaCcaur roof cupancy Signature of Applicant Date
/ L�� 10�2 f�oLI All roof coverings to be Class "B" or better '
046,or mohnnoid age Dam
O)WER-BUILDER VERIFICATW
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
® A. All the work authorized by this permit
B. A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. A portion of the work.(complete section below)
Contractor Address/City. Phone # State License # Type of work to
. vc aaviu:cu
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
• portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Persor/Firm Address/City Phone Number Type of work to be
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correcd. I have read and understand the
Owner-Builder Information (reverse side). /
6 12
Property Owners Sigimtur@
Job Adp" --paY r/"'"— 11� Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
City of Cupertino Building Department
CITY OF 10300 Torre Avenue
Aft
PE{�TINO Phone: (408)777-322
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner-builder you are the responsible party of record
on such a permit Building permits are not required to be signed by property owners unless they are
personally performing their own work If your work is being performed by someone other than yourself,you
may protect yourself from possible liability if that person applies for the proper permit in tris or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
If you plan to do your own work,with the exception of various trades that you plan to subcontract,you
should be aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work
(including materials and other costs) is$200 or more for the entire project, and such persons are not licensed as
contractors or subcontractors, then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding,federal social
security taxes,workers' compensation insurance,disability insurance costs,and unemployment compensation•
contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are
especially serious with respect to workers' compensation insurance.
For more specific information about your obligations under federal law, contact the Internal Revenue
Service (and,if you wish, the U.S. Small Business Administration). For more specific information about your
obligations under state law,contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale,property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees,.without a licensed contractor or
subcontractor, only finder limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder
building permit,erroineously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performing
their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License
Board in your community or at 1020 N Street,Sacramento,California 95814.
Please complete and return the enclosed owner-builder verification form so that we can confirm that
you are aware of these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
Building Department,
City of Cupertino •
Printed on Recycled Paper
al � *CITY OF CUPERTINCO
CUP TYOF O PERMIT APPLICATION FORM
APN # / / / b3 Date:
Building Address: T Mailing Addresst
ifferen from b ]ding.address):
1449- 4wt.w UL—
Owner's Name: Phone #:
M 4- IVN k P A R2-I Log - et't6 --;J� S �
Contractor: License #:
kWMC-0wNC-2
Contact: Phone:401'*T Cupertino Business License#:
M . 19AXIL-1 4*: tcoQ496i~S�s �-
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Job Description:
,Residential W (, / /L Commercial ❑
Sq.Ft. Floor Area: a t,o / ca.,.*— l j $/Sq.Ft.:
Cost of Project: Occupancy Group:
a
Type of Construction. Please check this b e is a
second-stdaddition: ❑
Project Size: Standard E 'Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> I OOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to IM Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <= IOOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investi ation fee BUILDING
Z 7 C,
I of 3
JkPPRovF-®
�----, p CE WQN THE CIV 01
G coe ►bo A%D
)ATE
�S1�01 play,a acifications MUST
is set at ,ao a ail times and it is an
oe kept on changes or alteration
lal ba make an ritten Permission
on same wu w` of Cupertino.
the boil in Deft City nd specifications
m ing of this plan ��a be ar.
The sfa P 4- 1e e.
iNALL ff . . of any Prop;`;
v rova� violation
.r aw Crty aomance or Mate Caw
RECEIVED
OCT
OCT 2 12
BY:
CITY OF CUPETUINO R°
BUILDING DIVISION PERMPl CONTRACTOR;INFORMATION°
IFILDINGADDRESS: MARTIN & JENNIFER PARRY PERMIT N`04100145
697 GALWAY DR
OWNER'S NAME: PERMITL55UEDATE
MARTIN & JENNIFER PARRY 10/21/2004
NE: SANITARY NO. CONTROL NO.
ARCHITECIVENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
yop LICENSED CONTRACTOR'S DECLARATION Job Description
m pp 1 hereby affirm that 1 am licensed under provisions of Chaplet 9(commencing
?
W wish Section? Mgaf Division3of the Badnevand Professions Code.and my license is
mreB mreaanderr=C1' OPEN=? CEILING�FLUO. LITS ���®
O License Class Lic.x �I
Z r p Dater—Cumoredr
a ARCHITECTS DECLARATION
���p
wa 1 understand my plans shall W used as public records
=d. LicensedPmfessivard JAN // 2005
S OWNER-BUILDER DECLARATION
<p 1 herehy affirm that 1 am eaempt from she Contractor's License Law for the
O O following reason.(Section 7131.5,Business and Profe:tions Cure:Any city or county
y w which requires a permit m opo I ❑
construct.alter,improve.demolish,or repair any,nd'him 2 7 0
FTs prima)osissuater.also requircathc applicant for such Permit to a signed statement
ze
that he is licensed pursuant the pravisioorthc Contractor's License Law(Chapter 9 Sq. Ft. Floor Area
0,FtIm
. (commencing with Section 7(M)of Division 3 or the Business and Professions Care)or
,63
that he is exempt therefrom and the basis for one alleged exemption,Any viohrion of
Section 7031.5 by any applicant for a permit subjects the applicant to s civil penalty of 3 EIA049RbcOccupancy Type
not..or Iran Five hundred dollars(5500).
I,as Owner of the property,or my employees with wages as their sole compensation,
will do IDI work.and the structure is not intended or offered for sale(Sec.7044.Business
and Profession Code:The Contractor's License Law docs not apply to an owner or Required Inspections
progeny who builds or improves thereon,and whodoes such work himself or through his
own employees,provided that such impreverecnu are not mended oraReaed for sale.H.
however,the building or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
O 1,as owner of the property,am exclusively contracting with licensed contractors to
carousal the project(Sec.7044,Business and Profusion Cade:)The Contractor's Li.
ecaue Law docs not apply to an owner of profanity who Wilds or improve themon,and,
who eenuacss for such projects with a contractor(s)licensed pursuant to the Contractor's
L are Law.
p.I am excmpyy/derr�Sae,7c, Dao F2rr lto au n,
Owner/�11TTf—�l f//Y'/I• l r/
WORK 'SCOMPENSATIONDECLARATION
1 hereby affirm under penally of perjury one of the following declarations:
1 hove and will maintain a Certificate of Consent to self-insure for Workers Compere
sation,as provided for by Section 37W of the Labor Code,for the performance of the
work for which Nis permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued.
My Worker's Com faensalino Insurance carrier and Polity number art:
Camcr. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(The str inn need not W compleed fine permit is fortune hoodred dollars($100)
or loss.)
I ceNfy that in the pednrmance of the work for which this permit is Issued,I shall not
LL..ploy any per. any solcrOn�q oIsfULmhjecuoline Workers'Compensation
Laws of Califor�n t V ll UU
Applicant
NOTICE TO APKWA'Prr.If,after making this Certificate of Exemption,you should
become subject to the Worker's Com pcwium provisions Of the labor Code,you must
0 forthwith comply with such provisions or this permit shall be deemed revoked.
Pr+c CONS"rRUCTTON LENDING AGENCY
" work
reby which himmmrrc issued( e30TI. agency l'm the performance of /
5 the work for which mit permit is issued(Sec.construction Inco Co.Civ.C.)
fA 0 Lender's Name
lIL 1<nacr's nddrns
V O 1 certify mal l have read this application and sum that he above information is
(y cornea.1 agree to comply with all city and county ordinances and state laws iclating to
�U building conitmnion,and hereby authorim represedoinsor this city toenter uponthe
} G above mentioned property rnr inspection purposes.
(We)agree In save.indemnify and keep harmless the City or Calcium,against
liabilities.judgmenu,costs and expenses which mayor any wayaccaur againslsaid City
J in consequence artier granting ofthis permit.
'—' APP NT NDERSTANDS AND WILL COMPLY WI H ALyli NON POINT Issued by: Date
SO LATIONS, tQII (G�(
Gam/ Re-roofs
Signature of ApplicambContraemr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof _
Will the applicant or future building occupant store Or handle haraNuus material
to defined by the Cupertino Municipal Code.Chapter 9.13,and the H0101 and Safety
ratio. yzss25532(a),Des NO
All roofs shall be inspected prior to any roofing material being installed.
Yes
-i
Will thea applicant mbuildin race mrnlmdeviecawhien If a roof is installed without first obtaining an inspection,I agree to remove
pp g«cupan quip
it hila dous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
imrkt?
Yes Nu
I have ded me h.oi smamrials requirements under Chapter 6.95 of the Califor
iiia Health h Saudi Code.Sections 255(15.25533 and 25534.1 orearsund maid de Wilding
Jncc n semi haw a mom,mm it is my responsibilirY a notify the«cupant of me
requi t r ma aWmetprioratiasaanccOraccoff of top Y. Signature of Applicant Date
_ �7 (D/ Z I (D(� All roof coverings to be Class "B" or better
Littler or autharind a far Dam